COPD Diagnosis*

Anthropometric Vitals

Demographics

UnscheduledScheduled

ConfirmedUnknown

Suspected

Suspected COPD

New COPD Diagnosis

Other

YYYY/MM/DD

Clients Name (please print)

Client Identifier TypeDate Visit

Date of BirthReferring health care provider

Provider identifier assigning authority

Reason for referral

Past Medications

Provider Identifier Type

Healthcare Professional Role Type

Postal / Zip Code

Lived Gender

Highest level of education

Living With

Yellow Zone Medications

Client Identifier Assigning Authority

Self Reported Ethnic Group

Sex Assigned at Birth

Gender diverseMale genderFemale gender

COPD Care Map for Primary CareInitial Assessment

N/A

N/A

N/A

N/A

YYYY/MM/DDe.g respirologist

e.g Regulatory body for physicians & surgeons e.g provider billing number

e.g Jurisdictional Health Number e.g OHIP YYYY/MM/DD

CaregiverPartner

< High school High school Post secondary< Bachelor’s degree

Bachelor’s degree Post secondary > Bachelor’s degree

Date Confirmed/Excluded(If uncertain indicate “unknown” in the provided field)

cm

kg

Height

Weight

BMI

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Medications

Patient has a spacing device

Does at least one prescribed medicationallow for a spacing deviceto be used?

Unfilled prescriptions. In the last 6 months has the patientbeen prescribed any COPDmedications he/she has not obtained.

Long Acting Muscarinic Antagonist (LAMA)

LAMA/LABA

ICS/LABA

ICS/LABA/LAMA

Antibiotics

Prednisone

Other

Other

Short acting β-agonist (SABA)

Respiratory Medications Drug Name Strength (Unit of Measure)

Dose form (device type) Route Rx Date

Long acting β-agonist (LABA)

Macrolide

NoYes

Age COPD was confirmed Spirometry attached#

N/A

Short acting muscarinic antagonist (SAMA)

Asthma COPD Overlap

*ensure a diagnosis of COPD is made with post-bronchodilator spirometry testing to meet the Canadian Thoracic Society criteriaPost-bronchodilator FEV1/FVC ratio < LLN or < 0.70

Appointment Type

YesScheduled No

YesPost Hospital Visit No

If yes: Within 7 days post-hospital visit Within 14 days post-hospital visit More than 14 days post-hospital visit

Oxygen Therapy: _______ L/ min at rest _______L/min on exertion _______ L / min during sleep

SABA use < 1 canister/ month > 1 canister/ month1-2 canister/ month

Other

YesPost ED Visit No

Other

Lives alone

Sp02 _______ L/min

Inhaled Corticosteroid (ICS)

Adherence issues known or suspected? Y/N

September 15, 2020 Version 2

4-7/year0-3/year ≥8/year

Breathlessness

Chest pain

Chest tightness

Colds that last longer than 7 days

CoughSputum production

Symptoms worse at night (including cough)

Wheeze

Frequent coldsIf yes frequency

NoYes

NoYesNoYesBarriers (If yes select from the list below)

(If yes select conditions from a list and indicate which relative)

Adherence

Cultural issue

Financial issue

Lack of private drug plan

Language

Literacy

Medication side effects

Other

Years smoked Pack years

x =Cig Smoked/day

Smoking

When was the last time you smoked a cigarette, even a puff?

Non-Smoker Smoker (# of cigarettes per day ____ )Ex-Smoker

1-6 months > 6 months < 1 month non-traditional tobacco (e.g. cigarettes/ cigarillo/ cigar)

Cannabis use e-cigarette user

Inhalation vapor user

N/A

Advise ArrangeAsk

beyond 6 months

within 6 months

not planning to quit

within a month

Allergy

Client Name Jurisdictional Health Number

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Respirologist

General Internist

Allergist

Urgent primary care visits Routine primary care visits

Are you planning to quit smoking?

Visit(s) to primary care physician in the last 12 months for COPD symptoms

If Yes, indicate the number of primary care visits for COPD in the last 12 months

Visit(s) to a specialist for COPD

No Unknown

No Unknown Last 12 MonthsYes

No Unknown Recent < 1yr Total # everYes

Yes

ED visits ever for COPD

Hospitalized ever for COPD

ICU admissions in the last 12 months

Systemic steroid use ever

COPD Healthcare Utilization

# ICU admissions # intubations

Date last used Total # ever

Family History of Lung Disease

Allergy

Alpha-1 Antitrypsin

Asthma

COPD

Parent Sibling

Parent Sibling

Parent Sibling

Parent Sibling

N/A

N/A N/ABarriers

Family History of COPD,  Allergy and/or Asthma

Smoking Status

Quit Duration

Quit Date

Smoke Type

Smoking Cessation Addressed

Smoking Cessation Quit Intentions

No UnknownYes

YYYY/MM/DD

Stages of Change Addressed

pre-contemplation contemplation preparation

action maintenance

Current Symptoms N/A

on exertionat rest

Sputum colour _______________________ Sputum consistency __________________ Sputum volume ________

traditional tobacco (e.g. smudging ceremonies)

hooka shisha

Hemoptysis

Yes No

Passive Smoking Risk

Physicial Exam N/A

Normal breath sounds Abnormal breath sounds

Bronchial (harsh and prolonged inspiration and expiration)

Crackles Reduced Breath Sounds

Wheezes

If abnormal, select auscultory finding

Barrel chested Clubbing Cachectic (skinny)

Vitals: HR __________ RR ___________ BP ____________

Nicotine Replacement Therapy (NRT)

Smoking Cessation Aids

NoYesEffect of substances addiction

NoYesSocial/Family issue

Limitation of activities at home

Decreased energy level

Sleep soundly

20

Pack Years

Environmental Controls

Air conditioning in summer

Central or hepa-filter vacuum

Dehumidifier (desired target < 50%)

Dust mite mattress cover

Dust mite pillow cover

Removed carpets

Heat exchanger

Heating gas/Oil

Heating electric/RadiatorAlternative to wood heat (fireplaces, wood

No SuggestedYesHumidifier in winter (desired target < 50%)

Humidifier all year round (desired target < 50%)

Non-feather blanket

Pets kept out of bedrooms

Regular furnace filter change

Remove pets from home

Wash linens in hot water

Wash pets once a week

Wear mask or respirator as needed

Other

No SuggestedYes

Environmental Control Measures in Place (If Yes, Select patient-reported, control measures in place. Optional: repeat questions for individuals with a secondary home.)

Client Name Jurisdictional Health Number

Modified Medical Research Council Classification

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mMRC 0: I only get breathless with strenuous exertion

mMRC 1: I get SOB when hurrying on the level or walking up a slight hillmMRC 2: I walk slower than other people of the same age on the level, or stop for breath when walking at my own pace

mMRC 3: I stop for breath after walking 100 meters or after a few minutes

CAT Score

5 Upper limit of normal in healthy non-smokers

Full-Time

Other

Triggers and Exposures

Occupational History

NoNo

UnknownUnknown

YesYes No UnknownYes

N/A

N/A

N/A

NoYesBeta Blockers

Cats

Chemicals

Cockroaches

Cold air/ Windy day

Dogs

Dust/Dust mites

Emotion/ Stress

Exercise

Fireplace/Woodstove

Food allergy

Fumes

Fungi/Mould

Grasses

High humidity

Medications

Outdoor pollution

Perfume/Air fresheners

Pollen

Ragweed

Respiratory Infections

Second hand smoke

Other

TriggersCategory Exposures

NoYes

If yes select patient reported triggers & exposures from list.

_____________________________________________ Current Employment___________________________________________________________________

N/A

mMRC 4: I am too breathless to leave the house or I am breathless when dressing or undressing

Impact level

< 10 Low

10 - 20 Medium

> 20 High

> 30 Very High

CAT Score _______________________________

CTS severity score (symptom burden and the risk of future exacerbations)

N/A

Mild: CAT < 10, mMRC 1, No AECOPD*

Moderate: CAT ≥ 10, mMRC ≥ 2, Low Risk of AECOPD*

Severe: CAT ≥ 10, mMRC ≥ 2, High Risk of AECOPD*

*Patients are considered at Low Risk of AECOPD with ≤ 1 moderate AECOPD in the last year (moderate AECOPD is an event with prescribed antibiotic and/or oral corticosteroids), and did not require hospital admission/ ED visit; or at High Risk of AECOPD with ≥ 2 moderate AECOPD or ≥ 1 severe exacerbation in the last year (severe AECOPD is an event requiring hospitalization or ED visit).

CAT Score (https://www.catestonline.org) N/A

Unknown

Current Employment Status: Check all the apply. Note - This includes self-employment and working from home:

Part-Time Shift work Modified duties Off work due to respiratory health Retired

Significant work exposure ________________________________________________________________________________________________

stoves, furnaces) or mitigation strategies

Aneurysms

Angina

Aortic Stenosis

Aortic Valve Regurgitation

Arrhythmias

Atrial Fibrillation

Cardiomyopathy

Cerebral Vascular Accident

Coronary Artery Disease

Congestive Heart Failure

Cor Pulmonale

Coronary Artery Bypass Surgery

Deep vein thrombosis

Defibrillator

Heart Disease

High Blood Pressure

Hyperlipidemia

Hypertension

Implantable Cardioverter

Mitral Valve Regurgitation

Myocardial Infarction

Myocarditis

Pacemaker

Pedal Swelling

Peripheral Vascular Disease

Syncope

Transient Ischemic Attack

A-1 Antitrypsin deficiency

ASA Reaction

Eczema

Emphysema

Lung Cancer

Chronic Bronchitis

Other Lung Disease

Pleurisy

Pneumonia

Pneumothorax

Pulmonary Edema

Pulmonary Effusion

Pulmonary Embolism

Pulmonary Hypertension

No UnknownYes

NoYesComorbid Conditions (If yes, select relevant comorbid diagnosis from the list provided)

Client Name Jurisdictional Health Number

N/AComorbidities

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L/Min

L/Min

L/Min

L/Min %

%

%

L/Min

L/Min

Spirometry PREActual

FVCFEV1

FEV1 / FVC

PEF

Actual % PredPOSTLLN

Pulmonary Function Test N/A

Mental Health

Anxiety

Dementia/Alzheimer

Depression

Panic Disorder

Diabetes

Hypothyriodism

Metabolic Syndromes

Metabolic

Respiratory

Anaphylaxis

Nasal Polyps

Oral Thrush

Rhinitis/ Sinusitis

Sleep Apnea

Upper RespiratoryTract Infection

Arthritis

Cancer

Cataracts/Glaucoma

Frequent Colds

GERD

Heartburn

Kidney Disease

Liver Disease

Osteopenia/Osteoporosis

Rheumatoid Arthritis

No UnknownYes No UnknownYesUpper Airways

DLCO ResultsNoYes N/A

Cardiovascular

Other

COPD Action Plan N/A

YYYY/MM/DD

YYYY/MM/DD

YYYY/MM/DD

# of Times

Written COPD action plan provided

Written COPD action plan revised

COPD action plan reviewed & not changed

Yellow or red zone of action plan followed,

NoYes

Additional Notes/ Plans

L/Min

L/Min

L/Min

%

%

%

Actual % Pred

Other

NoYesEducation provided at this visit

(Identify education provided by selecting from the list below)

Investigations

Chest CT Results

Bone Mineral Density Test (BMD Test)

Date of last ResultsYYYY/MM/DD g/cm²

N/A

Immunizations discussed

Influenza vaccination received

Date of last influenza vaccination

No UnknownYes

YYYY/MM/DD

Conjugated vaccine (PNEU-C-13)

Additional Notes/ Plans

Education Interventions

Adherence to medications

Barriers addressed

COPD Action Plan

COPD pathophysiology

Coping strategies addressed

Device technique optimal

Early recognition & treatment of exacerbations

Environmental tobacco smoke exposure

Exercise

NoYes

N/A

Poor Fair Good Excellent

Allergy

Client Name Jurisdictional Health Number

Immunizations

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N/A Referrals

Allergist

COPD Education Program/ CRE

Respirologist

Smoking cessation counselling/support

Dietitian

Mental health counselling

Sleep testing

Allergy testing

Home O2 assessment

ABGs

Social Worker

Pharmacist

Full PFT testing

Pulmonary Rehabilitation

OTN tele-monitoring program (if available)

Other specialist

No SuggestedYes

N/A

Patient understanding of education/Information provided at this visit

Follow-up Visit Scheduled in (time frame from current visit)

1 Week

2 Weeks

3 Weeks

1 Month

2 Months

3 Months

4-6 Months

6-12 Months

“Wait and see”

Other

N/A

Healthcare Professional Role Type Signature

YYYY/MM/DD

YYYY/MM/DDPolyvalent Pneumococcal vaccine

https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci.html

NoYes

Other (past disgnostics)

Alpha-1 Antitrypsin blood work done

Results _______________________________________________________________

NoYes

ABG on room air done and date (consider when FEV1 < 40% or resting Sp02 < 90%) NoYes

N/A

N/A

6 minute walk test NoYes N/A Results

Results: pH _____ PO2 _____ PC02 _____ HC03 _____ Sa02 _____ Date of last YYYY/MM/DD

Immunotherapy

Inhaler technique

Medications

Provide patient education materials

Self management goal

Smoking cessation

Triggers & environmental controls

Other

NoYes